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ss nucleus - summer 2008,  Personal Beliefs – GMC Guidelines

Personal Beliefs – GMC Guidelines

This is a personal paper by Dr Misselbrook and does not represent the official view of CMF, the RSM or any other body that he is associated with.

In March this year, the General Medical Council (GMC) published guidelines on Personal Beliefs and Medical Practice (PBMP). These aim to qualify and refine existing guidance set out in Good Medical Practice (GMP), published in 2006.

The new guidelines touch on several issues that are important for Christian doctors, such as referral for abortion, or sharing faith with patients. Therefore, we need to know what the guidance says and how we should respond to it as Christians.

Good Medical Practice

All medical students and doctors should have a working knowledge of GMP, a foundational document for all doctors practising within the UK.[1] GMP states that:

  • You must make the care of your patient your first concern. (Introduction, Duties of a Doctor)
  • You must treat your patients with respect whatever their life choices and beliefs. You must not unfairly discriminate against them by allowing your personal views* to affect adversely your professional relationship with them or the treatment you provide or arrange. [*This includes your views about a patient's age…culture….lifestyle, marital… status, race, religion or beliefs, sex, sexual orientation.] (Paragraph 7)
  • If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role. (Paragraph 8)
  • You must not express to your patients your personal beliefs, including political, religious or moral beliefs, in ways that exploit their vulnerability or that are likely to cause them distress. (Paragraph 33)

These general principles represent the broad ethical themes of beneficence and respect for autonomy, within the context of our professional responsibility. They also show respect for our own autonomy – paragraph 8 does not demand that we should do whatever the patient wants within the law, but rather deals with how we should act in a way to respect both the patient's autonomy and our own when we find them to conflict. These principles are an example of enlightened liberalism within a pluralistic post-Christian society that safeguards the rights and beliefs of all. These guidelines could be seen as an expression of Jesus' golden rule that we should 'in everything, do to others what you would have them do to you'.[2]

Paragraph 33 is a necessary addition to paragraphs 7 and 8. Again it emphasises our responsibility as professionals. Politicians and used car salesmen may exploit the vulnerable, but doctors must not. A Christian might ask, 'How can anything that declares the truth of the gospel ever be wrong?' But the Bible makes it clear that, not only must our message be right, but our methods must be righteous also. Jesus repeatedly refused the opportunity of forcing his message on others.[3] The gospel is not coercive. We should never exploit the vulnerable, but rather we should 'be completely humble and gentle'.[4] So we can broadly welcome the GMC guidelines and see them as defending the rights of all, including the rights of those with beliefs and principles that are different from the secular majority.

Personal Beliefs and Medical Practice

Just as all doctors should have a working knowledge of GMP, all CMF members need to understand the new supplementary guidance in PBMP.[5] There is no substitute for reading it, as this article is not meant to be an exhaustive guide! Some key elements of the supplement include (from this point onwards, all bulleted quotations in the article come from PBMP):

  • Personal beliefs and values, and cultural and religious practices are central to the lives of doctors and patients. (Paragraph 4)
  • Patients' personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness or treatment. They may also lead patients to ask for procedures which others may not feel are in their best clinical interests, or to refuse treatment which is. (Paragraph 5)
  • All doctors have personal beliefs which affect their day-to-day practice. Some doctors' personal beliefs may give rise to concerns about carrying out or recommending particular procedures for patients. (Paragraph 6)
  • This guidance…attempts to balance doctors' and patients' rights – including the right to freedom of thought, conscience and religion…– and advises on what to do when those rights conflict. (Paragraph 7)
  • Patients may find it difficult to trust you and talk openly and honestly with you if they feel you are judging them on the basis of their religion, culture, values, political beliefs or other non-medical factors. For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs. You must respect patients' right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options. However, if patients do not wish to discuss their personal beliefs with you, you must respect their wishes. (Paragraph 9)

These statements are welcome, and put the whole matter onto a level playing field. They especially protect those with religious faith against the likes of Richard Dawkins who seek to establish that atheism is somehow a natural and rational default position, and that any other starting point needs some special defence. It recognises that medicine cannot be separated from a holistic view of people themselves, and that belief systems are rightly included within healthcare's gaze. We should welcome the freedom these guidelines give to discuss faith sensitively with patients.

The guidelines remind us of the need for respect. We should be imitators of Christ, who '…taking the very nature of a servant…humbled himself...'[6] We are here to serve our patients, not judge them. No one should wish for the freedom to push insensitive or arrogant views down others' throats.

When are beliefs relevant to patient care?

  • You should not normally discuss your personal beliefs with patients unless those beliefs are directly relevant to the patient's care. You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views. Equally, you must not put pressure on patients to discuss or justify their beliefs (or the absence of them). (Paragraph 19)

Christians are called both to act for the general good of the community and to point to Jesus as the one who can bring every member of that community to a knowledge of God.[7] Our role as doctors employed by the secular state is primarily of enhancing and preserving our community by the common grace of medical care. There is nothing in the GMC guidelines that prevents the light of Jesus shining through our lives (if indeed it is there), and nothing to prevent us from responding to questions or to challenging situations in a sensitive and appropriate way, that may include discussing our own faith. However if we believe that our primary calling from God is to be an evangelist, it is inappropriate that we should seek state employment within the NHS to achieve this end. We would not be acting honestly to our employer or the community that pays us.

Nevertheless this guidance is not unproblematic - how can one define when one's beliefs are relevant to patient care? By and large if this is left for doctors and patients themselves to negotiate within an atmosphere of mutual respect there should be no problem. But problems could arise where third parties (eg relatives, other healthcare staff or managers) have an axe to grind.

Andrew Fergusson refers to this in a recent BMJ Careers article on these guidelines.[8] He cited the example of Tamie Downes, a Christian GP, who told a newspaper that eight of the women she had counselled regarding abortions had later taken their pregnancies to term. Dr Downes was referred to the GMC, despite there being no complaints from patients. 'Most Christian doctors would want to be involved in the process and I think they can do that legally and ethically. Here's a good doctor who gives patients the choice…if there is somebody malicious who wants to start a storm, or even an upset woman, there is a threat there,' said Dr Fergusson.

Fulfilling our responsibilities

  • …we expect [doctors] to be prepared to set aside their personal beliefs where this is necessary in order to provide care in line with the principles in Good Medical Practice. (Paragraph 8)

The key here is that one would only be expected to 'set aside...personal beliefs' where these prevented one from practising according to GMP. Whilst GMP respects the rights of all this should remain broadly unproblematic.

  • …It is not acceptable to seek to opt out of treating a particular patient or group of patients because of your personal beliefs or views about them. (Paragraph 25)

This paragraph is a response to the situation reported in 2007 where 'some Muslim medical students are refusing to attend lectures or answer exam questions on alcohol-related or sexually transmitted diseases because they claim it offends their religious beliefs…'[9]

Jesus was not a supporter of this kind of segregation; nor should we ever be.

What about abortion?

Within faith communities there are well recognised issues of principle around abortion, and sometimes other procedures and certain forms of contraception.

  • Patients may ask you to perform, advise on, or refer them for a treatment or procedure which is not prohibited by law or statutory code of practice … but to which you have a conscientious objection. In such cases you must tell patients of their right to see another doctor with whom they can discuss their situation and ensure that they have sufficient information to exercise that right… (Paragraph 21)
  • Where a patient who is awaiting or has undergone a termination of pregnancy needs medical care, you have no legal or ethical right to refuse to provide it on grounds of a conscientious objection to the procedure… (Paragraph 26)

In the UK we live within a society free within the bounds of the law, and part of that law includes the 1967 Abortion Act. It is not for us to put barriers up between those seeking abortions and those legally providing them. We need to give medical care for, say, complications after an abortion just as we would care for a patient with lung cancer due to smoking. However, the GMC have helpfully clarified that paragraph 26 of PBMP, quoted above, does not mean that doctors are obliged to sign abortion forms, perform the admission process (clerking) for patients being admitted for abortions, or refer patients directly to other doctors who they know will authorise the abortion.[10]

We are fortunate that the 1967 Abortion Act includes a 'conscience clause' so that no health worker is obliged to take part in the act of abortion. There are those such as Julian Savulescu who would deprive doctors of conscientious objection. Savulescu writes that:

a doctor's conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law…and the patient's informed desires. If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.[11]

We should thus see the GMC guidelines as a welcome defence of conscience, and a reasonable framework within which people with deeply differing views can work together within a common community under the law.

Give to Caesar what is Caesar's

How can Christians operate rightly within a secular society? When asked if good religious Jews should pay taxes to their Roman rulers Jesus answered, 'Give to Caesar what is Caesar's, and to God what is God's.'[12] Jesus gives us a principle that has been tested in far more hostile times than our own. This principle is echoed by Paul in his letter to Titus: 'Remind the people to be subject to rulers and authorities, to be obedient, to be ready to do whatever is good, to slander no one, to be peaceable and considerate, and to show true humility toward all men.'[13]

Our mandate is to obey both God and the GMC. Clearly there might be some situations in which we could not rightly do both, but our job is to try to resolve such tensions wherever possible, whilst speaking up for godly values in our pluralistic but democratic marketplace. Daniel worked successfully as a high level civil servant for 30 years in a thoroughly pagan culture before a final crunch came where, unusually, obedience to God necessitated disobedience to the ruling authority. If Daniel can make it work in sixth century BC Babylonia then hopefully we too can do so in most circumstances throughout a professional lifetime in the 21st century.

We should thank God that the GMC currently gives us a strong defence against the likes of Savulescu and a few other extreme utilitarians who would remove the right for individuals to exercise conscience within a democratic society. Whilst we can work with a good conscience to please both God and the GMC, then let us do so with heart and soul.

References
  1. www.tinyurl.com/8ml8a
  2. Mt 7:12a
  3. Jn 6:15
  4. Eph 4:2a
  5. www.tinyurl.com/5cw3rh
  6. Phil 2:7,8
  7. Mt 5:13-16
  8. Finch R. Trust in the GMC to lay down the law on beliefs. BMJ Careers 2008;336:155
  9. Sunday Times 2007; 7 October
  10. www.cmf.org.uk/news/?id=80
  11. Savulescu J. Conscientious objection in medicine. BMJ 2006;332:294-297
  12. Mt 22:21b
  13. Tit 3:1,2
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